Compliance with CPAP in elderly patients with OSA

doi:10.1016/S1389-9457(00)00011-3

Sleep Medicine

Volume 1, Issue 3, 1 July 2000, Pages 209-214

https://doi.org/10.1016/S1389-9457(00)00011-3 Get rights and content

Abstract

Background: Obstructive sleep apnea (OSA) is common in the general population and especially in the geriatric age group. Nasal continuous positive airway pressure (CPAP) is a highly effective treatment but can be difficult for some patients to use.

Objective: We investigated the question if older patients were less compliant with CPAP therapy than younger patients and may not realize its benefits.

Methods: We conducted a prospective, non-randomized study comparing use of CPAP in patients over age 65 with patients under age 65. One hundred and seven consecutive patients with a new diagnosis of obstructive sleep apnea were started on therapy with nasal CPAP. We obtained follow-up data on all 107 patients. Compliance with CPAP was assessed by patients subjective report of use and, in a subset of 21 patients, by objective measurement using a microchip installed in the CPAP unit that measures actual hours of use at therapeutic pressure.

Results: The percentage of patients using CPAP regularly was not different in the two groups: 70% of patients in the over age 65 group used CPAP regularly vs. 72% of patients under age 65. The over 65 group used CPAP 6.5 nights per week, an average of 6.5 h of use per night. The under 65 group was not significantly different, using CPAP 6.8 nights per week, a mean of 6.7 h of use per night.

Conclusion: Patients over age 65 are able to tolerate CPAP as well as patients under age 65.

Introduction

Obstructive sleep apnea is a very common medical condition. One study estimated that OSA, as defined as an respiratory disturbance index (RDI) of 5 events per hour or more, is present in about 24% of men and 9% of women ages 30–60 years [1]. The presence of an RDI greater than 5/h plus the complaint of excessive daytime sleepiness occurs in about 4% of men and 2% of women. In the elderly, the prevalence is estimated to be higher. Ancoli-Israel [2] reported on sleep disordered breathing in a community dwelling elderly population. She found that 62% had an RDI greater than 10, and 44% had an RDI greater than 20. Nasal continuous positive airway pressure (CPAP) is a highly effective treatment that can reliably eliminate snoring and obstructive breathing by applying air pressure through the nose and stabilizing the upper airway during sleep and preventing collapse of the upper airway. However CPAP should be used on a regular basis to be maximally effective. Inability to tolerate CPAP has been a significant problem in achieving effective treatment of OSA. Because CPAP can be cumbersome and difficult for many patients to use, we were concerned that our elderly patients might have difficulty obtaining the benefits of CPAP therapy. In our clinical practice we have seen a high percentage of patients over the age of 65 years with obstructive sleep apnea, and we questioned if our patients over the age of 65 years were able to tolerate CPAP any differently than patients below the age of 65 years. We examined our experience in 107 consecutive patients with obstructive sleep apnea specifically to look at the compliance with CPAP therapy in patients over the age of 65 versus patients under the age of 65.

Section snippets

Methods

Patients were seen at Mayo Clinic Scottsdale Sleep Disorders Center by one of two pulmonary sleep specialists (J.M.P. and P.J.L.). Patients seen initially for consultation were referred for polysomnography based on clinical indications suggestive of OSA such as excessively loud snoring, observed apneas by a bed partner, nocturnal choking or dyspnea, or excessive daytime sleepiness and fatigue. Polysomnography was performed by monitoring electroencephalogram (EEG), electrooculogram (EOG),

Results

We initiated CPAP therapy on 107 consecutive patients forming the basis of this study. There were 71 patients over the age of 65 years, 59 (83%) were males and 12 (17%) were females. The mean age was 72.8 years (range 65–87 years). The mean body mass index was 28.3 (range 15.6–44.9). The mean respiratory disturbance index in this older group was 44.5 events/h (range 10.5–91.1 events/h). The mean CPAP pressure setting was 7.8 cmH₂O (range 5–13 cmH₂O).

We initiated CPAP therapy in 36 patients

Discussion

Obstructive sleep apnea is a common medical condition in the general population and is especially common in the elderly. Young et al. have shown in middle aged adults age 30–60 years that 9% of women and 24% of men have sleep apnea [1]. The prevalence of sleep disordered breathing (SDB) varies in the literature depending on the definition of sleep apnea used. Severity of sleep apnea is usually defined as an apnea plus hypopnea index or a respiratory disturbance index (number of apneas plus

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Regular CPAP use for at least six days a week and 6.5 h per night is high (>70%) in young and older subjects initiating treatment [40], a result that is comparable with the present MAA follow-up study in middle-aged subjects. It was reported that 31 of 107 OSA subjects were intolerant to CPAP at three months [40]. Another study reported that six months afterward, less than 30% of subjects were still undergoing CPAP treatment [41].
The mandibular advancement appliance (MAA) is now recognized as a first-line therapy option for mild to moderate obstructive sleep apnea syndrome (OSAS). The aim of this follow-up study was to re-assess the long-term efficacy of MAAs provided to patients in a previous comparative study.
Sixteen subjects had participated in a previous comparative study in which the efficacy and compliance of two MAAs (Klearway – K and Silencer – S) were compared in a randomized cross-over design. At the end of the previous comparative study, subjects selected the MAA they preferred. Nine chose the K and seven the S. Fifteen subjects were available for a follow-up interview and 14 (4 women and 10 men; mean ± SEM: 51.9 ± 1.7 y.o.) agreed to participate in an overnight sleep recording at a hospital sleep laboratory from January to February 2009. The mean time lag between the end of the previous comparative study and the follow-up was 40.9 ± 2.1 months (range of 2.5–4.5 years). Comparisons were made across the three polysomnographic evaluations (PSGE): baseline, the night with the appliance of their choice at the end of the previous comparative study, and the follow-up night. Subjects completed the Epworth sleepiness scale (ESS), the fatigue severity scale (FSS), and a quality of life questionnaire (FOSQ).
At the follow-up, the respiratory disturbance index (RDI) remained significantly lower than baseline (p < 0.001). Questionnaire responses revealed that ESS, FSS, and FOSQ remained improved at follow-up (p < 0.02). Body mass index (BMI) increased slightly from baseline to follow-up (p < 0.05). Diastolic and systolic blood pressure and cardiac rhythm decreased significantly from baseline to follow-up.
The MAAs remained effective in improving RDI, sleepiness, blood pressure, cardiac rhythm, fatigue, sleep quality, and quality of life over a period of 2.5–4.5 years. The rise in BMI is a concern that merits further examination.
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There also have been several studies looking at compliance in the elderly. Parish and colleagues42 compared compliance in an elderly cohort (age older than 65 years) with that in a nonelderly cohort (younger than 65 years). Compliance at 3 months, measured by percentage of patients using CPAP and mean hours of nightly use, was not different between the two groups.
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Adequate CPAP compliance has been defined as greater than 4.5 h of CPAP use per night on a routine basis [39]. Most studies of CPAP compliance report “good compliance” as greater or equal to 4 h, and in a study of older adults without dementia, mean compliance was over 6 h per night [40]. Our laboratory has previously reported that the presence of depression was the only factor associated with noncompliance in this patient population [41].
Patients with Alzheimer’s disease (AD) and obstructive sleep apnea (OSA) experience disrupted sleep. This study examined the effect of continuous positive airway pressure (CPAP) on sleep parameters in AD patients with OSA.
A randomized placebo-controlled trial of 3 weeks of therapeutic CPAP (tCPAP) vs. 3 weeks placebo CPAP (pCPAP) followed by 3 weeks tCPAP in patients with AD and OSA. Polysomnography data from screening after one night and after 3 weeks of treatment were analyzed. Records were scored for percent of each sleep stage, total sleep time (TST), sleep efficiency (SE), sleep period (SP), time in bed (TIB), sleep onset (SO), wake time after sleep onset (WASO), and arousals. A randomized design comparing one night of pCPAP to tCPAP and a paired analysis combining 3 weeks of tCPAP were performed.
Fifty-two participants (mean age = 77.8 years, SD = 7.3) with AD and OSA were included. After one treatment night, the tCPAP group had significantly less % Stage 1 (p = 0.04) and more % Stage 2 sleep (p = 0.02) when compared to the pCPAP group. In the paired analysis, 3 weeks of tCPAP resulted in significant decreases in WASO (p = 0.005), % Stage 1 (p = 0.001), arousals (p = 0.005), and an increase in % Stage 3 (p = 0.006).
In mild to moderate AD patients with OSA, the use of tCPAP resulted in deeper sleep after just one night, with improvements maintained for 3 weeks.
Efficacy of two mandibular advancement appliances in the management of snoring and mild-moderate sleep apnea: A cross-over randomized study
2009, Sleep Medicine
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Regular CPAP use, for at least six days/week and 6.5 h/night, is high (>70%) in young and older patients initiating treatment [23], a result that is comparable with the present MAA comparative study in middle-aged subjects. It was reported that 31 of the 107 OSA subjects were intolerant to CPAP at three months [23]. Another study reported that six months afterwards less than 30% of patients were still undergoing CPAP treatment [24].
Mandibular advancement appliances (MAA) are a recognized alternative treatment to continuous positive airway pressure (CPAP) for mild-moderate obstructive sleep apnea syndrome (OSAS). The aim of this study is to assess the efficacy of and subject satisfaction with two MAA in the management of OSAS.
Five women and 11 men (47.9 ± 1.6 years), previously untreated with CPAP, were recruited from a sleep disorders clinic following a polysomnographic diagnosis of mild-moderate OSAS with Respiratory Disturbance Index (RDI) of 9.4 ± 1.1. A randomized single blind cross-over study was completed with both Klearway and Silencer (three months for each study arm). Subjects completed standardized questionnaires on sleep quality, sleepiness and functional outcomes (Functional Outcome Sleep Questionnaire: FOSQ). MAA satisfaction (e.g., comfort) and efficacy (e.g., reduction of respiratory noises, headache) were assessed by subjects and sleep partner.
The two MAA (Silencer 4.7 ± 0.9 and Klearway 6.5 ± 1.3) significantly reduced the RDI compared to the baseline night (10.0 ± 1.2, respectively p < 0.001 and p < 0.01). The RDI was slightly lower with the Silencer (p ⩽ 0.05) but subjects’ preference for comfort was in favor of the Klearway (Klearway 7.0 ± 0.4 vs Silencer 5.8 ± 0.4, p = 0.04). The Epworth score, FOSQ, respiratory noise and morning headache were also improved following use of both appliances (p ⩽ 0.05 to 0.001).
Although both MAA decreased RDI and subjective daytime sleepiness in a similar manner, the choice between various types of MAA needs to be taken into account when considering the benefit of RDI reduction over the benefit of subject compliance. The long term benefit of increased RDI reduction vs. a better subject compliance needs to be assessed in prospective studies.
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This therapy, which is applied by way of either a nasal or a full-face mask, generates positive airway pressure that acts as a pneumatic splint to reduce airway collapsibility. Although CPAP compliance is less than optimal in the general population, its acceptability in older persons is not significantly different than in younger patients [87,88], and simple interventions may improve compliance in this population [89,90]. Because of potential benefits related to CPAP therapy in regard to cognition [91] and subjective daytime sleepiness [92], this therapy should be considered in those patients who have neurocognitive disorders.
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Sleep apnea in the elderly: A specific entity?
2007, Sleep Medicine Reviews
Sleep apnea is highly prevalent in subjects after age 60, and affects older men and women similarly. Central apneas are often observed in addition to obstructive and mixed events. Pathogenesis of obstructive and central events during sleep in the elderly can be attributed to an amplification of well-established causes of sleep-disordered breathing (SDB) in younger adults. As in middle-aged adults, sleep-related complaints, cardiovascular diseases, depression and traffic accidents should prompt an evaluation by a sleep specialist. However, secondary enuresis and nocturia, cognitive impairment, ophthalmic conditions and repeated falls may be the main complaint in elderly subjects. Sleep studies in the elderly should systematically include reliable means to detect central apneas and periodic leg movements. Untreated SDB in the elderly appears to have a lesser impact on mortality than in middle-aged adults. However, the typical morbidity associated with the disorder in younger adults is observed in the elderly. Elderly symptomatic SDB patients tolerate CPAP no differently than younger patients and should be effectively treated. In conclusion, whether sleep apnea in the elderly represents a specific entity or the same disease as in younger subjects, with some distinctive features, is still unclear. Further research, in particular focusing on the impact of age on SDB outcomes, is needed.

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Original articleCompliance with CPAP in elderly patients with OSA

Abstract

Introduction

Section snippets

Methods

Results

Discussion

Clin Geriatr Med

Chest

Chest

Chest

Lancet

Lancet

Chest

Chest

Clin Geriatr Med

The occurrence of sleep disordered breathing in middle-aged adults

N Engl J Med

Sleep-disordered breathing in community-dwelling elderly

Sleep

Comparison of sleep disordered breathing among healthy elderly in the seventh, eighth, and ninth decades of life

Sleep

Neuropsychological dysfunction in sleep apnea

Sleep

Original article
Compliance with CPAP in elderly patients with OSA